Deprescribing and medication optimization in hospitalized older people with multimorbidity and polypharmacy: what larger scale multi-centre clinical trials tell us

In multimorbid older patients with polypharmacy, hospitalization can provide opportunities for deprescribing and medication optimization through close and repeated scrutiny of polypharmacy by both physicians and pharmacists in a controlled clinical environment. Structured medication review facilitates deprescribing of dangerous or inappropriate medications as well as medication optimization that should in theory reduce risk of adverse clinical outcomes in these patients, in particular rehospitalization, emergency department attendance or all-cause mortality. There are numerous clinical trials describing interventions designed to detect and ameliorate adverse or inappropriate prescriptions in multimorbid older patients with polypharmacy in various clinical settings but relatively few trials that specifically deal with such interventions in hospitalized older patients. The current narrative review focuses on larger-scale, multi-centre clinical trials of deprescribing and medication optimization interventions in older multimorbid patients with polypharmacy that report clinically important endpoints relating to interventions designed to promote deprescribing and medication optimization. We conclude that no single deprescribing/medication optimization intervention has demonstrated consistent clinically relevant endpoint efficacy in large scale randomized trials involving hospitalized older patients with multimorbidity and polypharmacy. Future clinical trials must therefore adapt their intervention design to address the challenge of polypharmacy and associated inappropriate prescribing in this rapidly growing population.